Anti-Rods and Rings Autoantibodies in a Patient With Hepatitis C Virus Infection

Dear Editor The fluorescent antinuclear antibody (FANA) test is widely used for the detection of systemic autoantibodies. Moreover, the fluorescent patterns seen with the FANA test have specific clinical significance [1, 2]. We recently observed an unfamiliar FANA pattern with several small cytoplasmic rod and ring immunofluorescence known as anti-rods and rings (RR) autoantibodies— the first instance in Korea—in a patient with hepatitis C virus (HCV) infection who received combined interferon (IFN) and ribavirin treatment [3-8]. A 69-yr-old man was admitted to Ajou university hospital in Korea in July 2014 for jaundice due to liver cirrhosis. On admission, his condition worsened owing to hepatic failure. He had been diagnosed as having HCV infection, hypertension, and type 2 diabetes in 2001. He refused medical care until 2009, when he received treatment with IFN and ribavirin for one year. The treatment was discontinued because of ineffectiveness. There was no other history of supportive treatment, including herbal medication. On admission, the patient developed sudden jaundice with the following laboratory results: total bilirubin, 21 mg/dL; direct bilirubin, 15.0 mg/dL; ALT, 78 U/L; and AST, 265 U/L. As there were no previous FANA test data available, the physician requested a FANA test to rule out autoimmune hepatitis as the cause of hepatic failure [7]. The FANA test was performed by using the HEPANA test with HEp-2 cells (Medical & Biological Laboratories Co., Ltd., Nagoya, Japan) and was read with a Zeiss Axio Imager A1 (Carl Zeiss Inc., Germany). A novel finding on the FANA test included several small cytoplasmic RR immunofluorescences (Fig. 1A). The result was reproducible with a titer of 1:640. Experts at another laboratory confirmed the pattern as anti-RR autoantibodies by using an autoimmune target (AIT) test (ImmunoThink Co., Seoul, Korea). Other reagents, such as HEp-2 ANA slides (INOVA Diagnostics, San Diego, CA, USA) also showed the RR pattern [3-8]. However, Kallestad HEp-2 cell line substrate (Bio-Rad Laboratories, Hercules, CA, USA) showed other cytoplasmic patterns, such as autoantibodies recognizing mitotic spindle apparatus-related antigens, instead of the RR pattern (Fig. 1B). This discrepancy may be due to differences in the conditions used for particular tissue cultures and the fixation of HEp-2 cells. Therefore, all commercial HEp-2 slides may not be reactive to anti-RR autoantibodies [6, 8]. The patient developed acute renal failure likely owing to hepatorenal syndrome at admission and died on day 17 post-admission despite supportive treatment.